CJR: Does Your Agency Have the Innovative Strategies to Deliver on Expectations?

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1 CJR: Does Your Agency Have the Innovative Strategies to Deliver on Expectations? Speaker(s): Chris Chimenti, MSPT Dan Kevorkian, MSPT Session Type: Educational Sessions Session Level: Intermediate This information is the property of the author(s) and should not be copied or otherwise used without the express written permission of the author(s). Home Health Section of the American Physical Therapy Association Page 1 of 34 total pages

Understand details of the CJR program as described in the 2016 Final Rule published by CMS Define

2 CJR: Does Your Agency Have the Innovative Strategies to Deliver on Expectations? Chris Chimenti, MSPT Dan Kevorkian, MSPT APTA CSM San Antonio, TX February 16, 2017 Objectives Understand details of the CJR program as described in the 2016 Final Rule published by CMS Define important, innovative strategies home health agencies can pursue to create value in this new model of care. Recognize the permanent impact this program will have on home health physical therapy practice. Learn from the experiences of a home health agency directly impacted by CJR across multiple geographic areas. 1

Acronyms Comprehensive Care for Joint Replacement (CJR) Bundled Payment for Care Improvement (BPCI) Began in 2013 Voluntary Similar to CJR Demand for TJR Why CJR?

solvency Goals of CJR (and BPCI) Eliminate variation (quality, experience) Reduce fragmentation Reduce cost (variance $16,500 $33,000) *2.5 Million Americans Living with an Articifical Hip, 4.

3 Acronyms Comprehensive Care for Joint Replacement (CJR) Bundled Payment for Care Improvement (BPCI) Began in 2013 Voluntary Similar to CJR Demand for TJR Why CJR??? * Prevalence of TKR/THR= 7 million Americans (2014) ** THR 174% 1 0 TKR 673% Revisions will be needed Current spending $7 billion/year 10,000 baby boomers/day through 2031 Medicare solvency Goals of CJR (and BPCI) Eliminate variation (quality, experience) Reduce fragmentation Reduce cost (variance $16,500 $33,000) *2.5 Million Americans Living with an Articifical Hip, 4.7 Million with an Artificial Knee. million-americans-living-with-an-artificial-hip-47-million-with-an-artificial-knee.htm. Accessed on 11/11/16. **Projections of Primary and Revision Hip and Knee Arthroplasty in the United States from 2005 to Kurtz S, Ong K, Lau E, et al; J Bone Joint Surg Am April; 89 (4):

4 Shift Do you remember 10+ Therapy? CJR Overview * CMS Final Rule Trigger event MS DRG 469 & 470 (Major joint replacement) Automatic, mandatory enrollment First of its kind 67 regions across U.S. ~ 800 hospitals in 33 states Destination hospitals Began April 1, 2016 Ends 2020 Expected to generate $343 million over 5 year period BPCI takes precedence in overlap *Medicare Program; Comprehensive Care for Joint Replacement Payment Model for Acute Care Hospitals Furnishing Lower Extremity Joint Replacement Services. Accessed on 11/11/16. 3

Hospitals On The Hook Target price 4 separate

levels) Shifts to 100% regional in years 4 and 5

discharge Target price based upon discount of

reconciliation UNDER target= Incentive payment

5 Hospitals On The Hook Target price 4 separate prices Historical spending (hospital + regional levels) Shifts to 100% regional in years 4 and 5 3 days prior Hospital admission 90 days post discharge Target price based upon discount of historical cost Annual retrospective reconciliation UNDER target= Incentive payment OVER target= Payment penalty Annual Balancing Act Target Price Actual Spending 4

hospitalization Inpatient psychiatric facility IRF/SNF Home health Outpatient services

6 What s Included in the Target Price? DRG and Medicare A/B spending Related services Physician services Inpatient hospitalization Inpatient psychiatric facility IRF/SNF Home health Outpatient services Clinical laboratory DME Part B medications Hospital readmission Moving Target Target prices adjusted annually Competition among hospitals in MSA 5

Hospitals may have eased in Increasing motivation Track post acute charges Data

7 Progression of Gain/Loss Upside opportunity in Year 1 Capped at 20% throughout program Downside risk phased in beginning Year 2 Progress to 20% in years 4 and 5 Hospitals may have eased in Increasing motivation Track post acute charges Data mining How Do YOU Get Paid? Traditional Medicare reimbursement Rates and rules remain constant 6

8 Not Just About The $$$ Not Just About The $$$ Required measures 1. Hospital Level Risk Standardized Complication Rate (RSCR) Acute MI Pneumonia or sepsis within 7 days of admission Surgical site bleeding, pulmonary embolism, or death within 30 days of admission Periprosthetic joint infection, or wound infection within 90 days, mechanical complications 2. Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) 32 questions about hospital experience Voluntary measures Patient reported outcomes (PRO) Function Where can HH PT demonstrate value? 7

9 Not Just About The $$$ Quality matters! Required measures Hospital Level Risk Standardized Complication Rate (RSCR) Acute MI Pneumonia or sepsis within 7 days of admission Surgical site bleeding, pulmonary embolism, or death within 30 days of admission Periprosthetic joint infection, or wound infection within 90 days, mechanical complications Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) 32 questions about hospital experience Voluntary measures Patient reported outcomes (PRO) Function THR/TKR Cost Distribution Post Acute 39% Acute 61% Sixty Percent of Hospitals Must Reduce Costs for Joint Replacement Under New Medicare Demo or Face Penalties. percent of hospitals must reduce costs for joint replacement under ne. Accessed on 4/7/16. 8

Trivia Question What are the two most significant cost saving opportunities related to post acute charges? BPCI cost reduction levers 1. Hospital LOS 2. Implant cost 3. Lower cost sites of service 4.

10 Trivia Question What are the two most significant cost saving opportunities related to post acute charges? BPCI cost reduction levers 1. Hospital LOS 2. Implant cost 3. Lower cost sites of service 4. Discharge to home 5. Readmission rate Doran JP, Zabinski SJ. Bundled payment initiatives for Medicare and non-medicare total joint arthroplasty patients at a community hospital: bundles in the real world. J Arthroplasty Mar; (3) Epub 2015 Jan 23. THR/TKR Post Acute Cost $122 $91 $604 $1,675 $2,123 *$1,155 *$5,034 *$1,568 *SNF *IRF * Hospital Readmission Home Health Physician Outpatient DME LTACH Sixty Percent of Hospitals Must Reduce Costs for Joint Replacement Under New Medicare Demo or Face Penalties. percent of hospitals must reduce costs for joint replacement under ne. Accessed on 4/7/16. 9

Kiridly DN, Karkenny AJ, Hurtzler LH, et al. J Arthroplasty. 2014 Aug;29(8):1545 7.

11 High Cost of Hospital Readmission Hip and knee arthroplasty patients (n= 2,026) Average daily cost of a 30 day readmission varied $13,000 21,000. The effect of severity of disease on cost burden of 30 day readmissions following total joint arthroplasty (TJA). Kiridly DN, Karkenny AJ, Hurtzler LH, et al. J Arthroplasty Aug;29(8): Long Road Comparison of Home Health Care Physical Therapy Outcomes Following Total Knee Replacement With and Without Subacute Rehabilitation. Chimenti C, Ingersoll G. Journal of Geriatric Physical Therapy. 2007;30(3):

Unique Position Home Health is the lowest cost inpatient provider High level of flexibility allows for truly

12 Importance of Home Health Innovation Must meet the new needs of bundled payment challenges Improve quality delivery Decrease costs Prevent avoidable complications Address patient issues immediately Home Health s Unique Position Home Health is the lowest cost inpatient provider High level of flexibility allows for truly customized care plans However, if your agency is still seeing ortho patients for 3wk4 or 2wk8 you will be left behind 11

Home Health Cost Prior to bundled payment, cost was not a factor in establishing care plan Agencies were focused on maximizing revenue through OASIS

Therapy Utilization Therapy Utilization Home Health Cost CJR hospitals will be looking to partner with HH agencies who are willing to control utilization

13 Home Health Cost Prior to bundled payment, cost was not a factor in establishing care plan Agencies were focused on maximizing revenue through OASIS scoring and therapy utilization Must move to a value based plan of care What is the greatest value I can get for the least amount of cost Controlling Therapy Utilization Therapy Utilization Home Health Cost CJR hospitals will be looking to partner with HH agencies who are willing to control utilization and balance with quality delivery HHRG Therapy Thresholds To Meet or not to Meet? Provide value over volume Evidenced based practice vs. Cookie Cutter therapy 12

True Value of Home Health for Joint Replacement Patients Take a step back and think about the true value of home health for joint replacement patients Immediate therapy assessment within 24 hours

as soon as possible Historical BPCI Model 2 Successes CJR is set up virtually identically to BPCI Model 2 90 day risk period for DRGs 469 / 470 Lewin Group Early studies of BPCI episodes from Q4 2010

14 True Value of Home Health for Joint Replacement Patients Take a step back and think about the true value of home health for joint replacement patients Immediate therapy assessment within 24 hours Heavily front loaded visits to address concerns and mobility issues Short Term while patient remains homebound Responsiveness to emergent needs Preparing patients for transfer to outpatient therapy as soon as possible Historical BPCI Model 2 Successes CJR is set up virtually identically to BPCI Model 2 90 day risk period for DRGs 469 / 470 Lewin Group Early studies of BPCI episodes from Q Q show positive impact in cost with approx 10 15% savings in Model 2 Lower Extremity Joint Replacement (LEJR) Trends in LEJR include : Decreased Inpatient PAC utilization Increased Home Health Utilization Source: Lewin Analysis of Q Q standardized Medicare payment outcomes and enrollment data for BPCI participants and comparison group available at EvalRpt1.pdf 13

BPCI Changes Noted Lewin Group $5,000.00 $4,500.00 $4,000.00 $3,500.00 $3,000.00 $2,500.00 $2,000.00 $1,500.00 $1,000.00 $500.

15 BPCI Changes Noted Lewin Group $5, $4, $4, $3, $3, $2, $2, $1, $1, $ $0.00 Before BPCI After BPCI Readmit SNF HHA Baseline costs from Advisory Board Episodic Cost Profiler How Can YOU Stand Out? 14

Medicare B Negotiated payment with anchor hospital *Oldmeadow LB, McBurney H, Robertson VJ.

16 Top 20 List #1 Pre Surgical Visits Assess, educate, & communicate Home environment DME needs Social supports Risk Assessment & Predictor Tool (RAPT)* Surgeon & NN Pre surgical class 2006 OIG Advisory Opinion Payment Medicare B Negotiated payment with anchor hospital *Oldmeadow LB, McBurney H, Robertson VJ. Predicting risk of extended inpatient rehabilitation after hip or knee arthroplasty. J Arthroplasty Sep; 18(6):

Standardization of care Avoid specific # visits PT Now Clinical Summary

17 #2 PT Only Admissions Autonomous Practitioner SN, OT, HHA PRN Waiting on the nurse #3 Evidence Based Care Established care pathways Best practice Standardization of care Avoid specific # visits PT Now Clinical Summary THA, TKA PubMed Alerts 16

18 #4 Falls Prevention DME Education Balance/strength Medical complications #5 Patient Education Materials Self management Limits phone calls Patient satisfaction 17

19 #6 Timely Care Admission within 24 hours 7 days/week Optimize safety Identify complications Facilitate progress Patient satisfaction Highest acuity Set plan in motion #7 Front Loading 18

sensitivity 72% specificity** *Evaluation of the patient with suspected deep vein thrombosis. Ebell M. J Fam Pract.

20 #8 Medication Reconciliation Every visit Education Prevent errors Hospital readmission Homan s sign #9 DVT Monitoring 56% sensitivity (identify true positive) 39% specificity (identify true negative)* Wells Criteria 10 criteria 88% sensitivity 72% specificity** *Evaluation of the patient with suspected deep vein thrombosis. Ebell M. J Fam Pract. 2001;50(2): **Does this patient have deep vein thrombosis? Wells, PS, et al. JAMA Jan 11;295(2):

21 #10 DVT Monitoring v2 #11 Constipation Protocol Opioid Induced Constipation (OID) 20

22 #11 Constipation Protocol Opioid Induced Constipation (OID) Senokot S daily; Miralex twice a day If no BM x 3 days, give Magnesium Citrate ½ bottle If no + result, then give the other ½ bottle the next day Contact physician #12 Vital Sign Assessment BP, PR, RR, O2 sat, Temp, Pain Lung sounds 21

23 #13 Surgical Wound Management State practice act Close monitoring S&S infection Dehiscence Nurse Navigator #14 Communication! Collaboration = Quality 22

Dual Eligible Beneficiaries and Potentially Avoidable Hospitalizations.

24 #15 Manage Complications Prompt, priority action DVT, pain, infection, cardiopulmonary. #16 Prevent Readmission 25% hospital readmissions are potentially avoidable* *Segal, M. (2011). Dual Eligible Beneficiaries and Potentially Avoidable Hospitalizations. Baltimore, MD: Centers for Medicare and Medicaid Services Retrieved from: Statistics Data and Systems/Statistics Trends and Reports/Insight Briefs/downloads/PAHInsightBrief.pdf 23

25 #17 Patient Satisfaction Hospitals/surgeons like happy patients! Word of mouth advertising #18 Engage Your Staff Why do I have to do things differently? Why is CJR important to me? Educate Focus Hospital readmission Efficient return to function 24

appointments Early detection of complications Begins day 1

26 #19 Telehealth CMS allowing payment for telehealth Billed through hospital outpatient Rural or urban areas Flexibility with follow up appointments Early detection of complications Begins day 1 Outpatient #20 Discharge Planning Timely scheduling Transportation plan Copays 25

BPCI CJR BPCI program allowed physician group practices to control their own bundles CJR shifts the risk and control to the episode initiating hospitals Visibility into surgeon

27 BPCI CJR BPCI program allowed physician group practices to control their own bundles CJR shifts the risk and control to the episode initiating hospitals Visibility into surgeon practices Paying attention now Hospitals are slow to react CJR began in April of 2016, however only upside risk was in place until December 31 st This means that hospitals are not at risk to lose money. That is until January 1 st of this year Hospitals have started to take on risk, however don t expect immediate reactions Medicare claims data lags by at least 6 months, so expect opportunities to partner through this year. Moral of the story: Don t get discouraged by constantly running into closed doors. You may just be ahead of the curve! 26

Programming to avoid readmissions Ability to manage urgent issues Fiscally responsible providers Episode Initiators Don t Know what they Don t Know Hospitals are aware of inpatient practices, but

28 What is a Episode Initiator Looking For in a Partner? Success in BPCI happens when clinical decision making drives the care Quality Hospitals are not looking for the cheapest provider Hospitals are looking for partners with: Exceptional Communication Programming to avoid readmissions Ability to manage urgent issues Fiscally responsible providers Episode Initiators Don t Know what they Don t Know Hospitals are aware of inpatient practices, but lack the knowledge of post acute providers In earliest conversations, most time was spent educating Episode Initiators on Home Health Billing and practices Erroneous assumptions by Eis included believing: # of Days impacts total cost HH agencies added nursing for additional revenue Home health aide and social work increase cost LUPAs were best practices 27

Success = Clinical AND Financial If clinical outcomes suffer, no one shares in savings programs Must be a good partner in achieving clinical outcomes Have a plan when things

Ensuring progress as expected Avoiding complications and early identification of issues Immediate reporting to physician/care managers Surgeons want to hear from us Hospitals

29 Success = Clinical AND Financial If clinical outcomes suffer, no one shares in savings programs Must be a good partner in achieving clinical outcomes Have a plan when things start to go downhill Are you asking the right questions during patient visits? Are you getting the most out of each visit? Ensuring progress as expected Avoiding complications and early identification of issues Immediate reporting to physician/care managers Surgeons want to hear from us Hospitals will have access financial and performance data on surgeons and begin work to create efficiencies Surgeons must be engaged in this process if successful changes are to be implemented Do your surgeons understand the implications? 28

Readmission rates and what practices you have established to reduce Show the value your company can add to a bundle Have a plan to assist

30 How to Earn Partnerships? Share previous outcomes and successes Ensure that you are currently driving quality in HHCAPS and other measures Understand your Readmission rates and what practices you have established to reduce How to Earn Partnerships? Show the value your company can add to a bundle Have a plan to assist in getting patients home vs. SNF/IRF Immediate service 24 hour admissions Simply cutting visits does not breed success Readmissions are costly what are you doing to avoid these and other complications Leverage HH as lowest cost provider 29

31 How to Earn Partnerships? Have ability to share ongoing outcomes Prepare to report data on HHRG rates, therapy visit numbers, key quality metrics (readmissions, clinical outcomes) Proactive transparency Are you ready to be a Collaborator? CJR models allow for post acute partners to take risk (CJR collaborators) Other providers (physicians, post acute providers) must provide direct services to patients or play a significant role in CJR care redesign activities to participate in gainsharing Gainsharing payments to collaborators: must come from gainsharing payments from Medicare, or from internal cost savings AND Payments cannot exceed 50% of Medicare reimbursement for services collaborator provided to patient CJR collaborators cannot pay more than 50% of the total downside payments owed by the hospital to Medicare 30

CJR available waivers CJR allows for certain exceptions to current laws that would could otherwise be seen as a violation of anti kickback statutes called Beneficiary Incentives These are known as

Patients not required to spend 3 days in hospital before going to a SNF (applies in years 2 5 of the program) Patients can only go to SNFs rated 3 star or higher on Medicare s Nursing Home Compare

32 CJR available waivers CJR allows for certain exceptions to current laws that would could otherwise be seen as a violation of anti kickback statutes called Beneficiary Incentives These are known as CJR Waivers which include: Post discharge home visits from non MD staff allowed (outside of home health) Telehealth services allowed and billed through hospital /Physician outpatient services Patients not required to spend 3 days in hospital before going to a SNF (applies in years 2 5 of the program) Patients can only go to SNFs rated 3 star or higher on Medicare s Nursing Home Compare system Patient Engagement Waivers Pitfalls Over promising / Under delivering Avoid discussions regarding specific numbers of visits Remember, we are required to develop individualized care plans which are reasonable and necessary We can establish best practices and protocols, but care must be individualized Communication Episode initiators want to be kept in the loop for things outside the norm Ensure process and expectations for communications are established 31

Pitfalls Ensure HH staff are educated Don t assume that clinicians, clinical supervisors are aware of agreements we have made Ensure that an appropriate amount of time is spent in

identification of complications and actions to avoid readmissions Lessons Learned There is not 1 answer to controlling cost and improving quality Home Health is a valuable tool for

33 Pitfalls Ensure HH staff are educated Don t assume that clinicians, clinical supervisors are aware of agreements we have made Ensure that an appropriate amount of time is spent in training on: What is the CJR program How to identify CJR patients at an agency level Expectations for Clinicians including protocols, best practices and communication processes Early identification of complications and actions to avoid readmissions Lessons Learned There is not 1 answer to controlling cost and improving quality Home Health is a valuable tool for success in BPCI/CJR programs Leverage home health benefits with your specific ability to meet the needs of your partner Focus on clinical quality 1 readmission is more costly than a SNF utilization 32

34 Conclusions Value based purchasing is the wave of the future Uncertainty with new administration Expect to see additional alternative payment models CABG/MI bundled program is coming Thank You. Chris Chimenti, MSPT Dan Kevorkian, MSPT

Redesigning Post-Acute Care: Value Based Payment Models

Redesigning Post-Acute Care: Value Based Payment Models Liz Almeida-Sanborn, MS, PT President Preferred Therapy Solutions This session will address: Discussion of the emergence of voluntary and mandatory